The fact that technology is rapidly transforming health care should come as no surprise to anyone. From robotic arms that perform surgery tonanorobots that deliver drugs through the bloodstream, the days of being tended to by the human country doctor seem to have fully given way to machines and software more in keeping with the tools of Dr. McCoy from “Star Trek.”

However, technology’s evolutionary impact on health care isn’t all shooting stars and bells and whistles. Some of health care’s most important changes can slip beneath the radar due to their more pedestrian presentation, but that doesn’t mean they aren’t just as revolutionary as mini robots zipping through veins. Take the burgeoning field of health informatics, for example. A specialization that combines communications, information technology, and health care to improve patient care, it’s at the forefront of the current technological shift in medicine. Here are six ways it’s already transforming health care.

1. Dramatic Savings

Health care isn’t just expensive; it’s wasteful. It’s estimated that half of all medical expenditures are squandered on account of repeat procedures, the expenses associated with more traditional methods of sharing information, delays in care, errors in care or delivery, and the like. With an electronic and connected system in place, much of that waste can be curbed. From lab results that reach their destination sooner improving better an more timely care delivery to reduced malpractice claims, health informatics reduces errors, increases communication, and drives efficiency where before there was costly incompetence and obstruction.

2. Shared Knowledge

There’s a reason medicine is referred to as a “practice,” and it’s because health care providers are always learning more and honing their skills. Health informatics provides a way for knowledge about patients, diseases, therapies, medicines, and the like to be more easily shared. As knowledge is more readily passed back and forth between providers and patients, the practice of medicine gets better — something that aids everyone within the chain of care, from hospital administrators and physicians to pharmacists and patients.

3. Patient Participation

When patients have electronic access to their own health history and recommendations, it empowers them to take their role in their own health care more seriously. Patients who have access to care portals are able to educate themselves more effectively about their diagnoses and prognoses, while also keeping better track of medications and symptoms. They are also able to interact with doctors and nurses more easily, which yields better outcomes, as well. Health informatics allows individuals to feel like they are a valuable part of their own health care team, because they are.

4. The Impersonalization of Care

One criticism of approaching patient care through information and technology is that care is becoming less and less personal. Instead of a doctor getting to know a patient in real time and space in order to best offer care, the job of “knowing” is placed on data and algorithms.

As data is gathered regarding a patient, algorithms can be used to sort it in order to determine what is wrong and what care should be offered. It remains to be seen what effects this data-driven approach will have over time, but regardless, since care is getting less personal, having a valid and accurate record that the patient and his care providers can access remains vital.

5. Increased Coordination

Health care is getting more and more specialized, which means most patients receive care from as many as a dozen different people in one hospital stay. This increase in specialists requires an increase in coordination, and it’s health informatics that provides the way forward. Pharmaceutical concerns, blood levels, nutrition, physical therapy, X-rays, discharge instructions — it’s astonishing how many different conversations a single patient may have with a team of people regarding care, and unless those conversations and efforts are made in tandem with one another, problems will arise and care will suffer. Health informatics makes the necessary

coordination possible.

6. Improved Outcomes

The most important way in which informatics is changing health care is in improved outcomes. Electronic medical records result in higher quality care and safer care as coordinated teams provide better diagnoses and decrease the chance for errors. Doctors and nurses are able to increase efficiency, which frees up time to spend with patients, and previously manual jobs and tasks are automated, which saves time and money — not just for hospitals, clinics, and providers, but for patients, insurance companies, and state and federal governments, too.

Health care is undergoing a massive renovation thanks to technology, and health informatics is helping to ensure that part of the change results in greater efficiency, coordination, and improved care.

Q: How will the additional specificity required by ICD-10 pose a challenge for clinicians and the way that they currently track patient information?A: For clinicians with “simple” requirements – such as specialists or those that don’t perform too many different diagnoses or procedures the transition will be annoying but not catastrophic. For primary care and other physicians that see a wide variety of conditions or perform many different kinds of procedures or diagnoses they will have more work and will take a little more time to transition.

Q: Is there a potential for a negative impact on patient care as kinks are worked out during the transition?A: In the short term there will may be a negative impact on patient care as visits may now take longer on the administrative side and reduce the amount of time practice staff spend with patients on the clinical side.

Q: What special challenges will come with the ICD-10 implementation in the United States, as opposed to the rest of the countries that use it?A: There are many more challenges in the USA because we have an intermediated payer system with many payers that care delivery organizations need to support on behalf of their patients. Even a small clinic will have to deal with many different payers that have their own payment rules and processes. Large institutions will have even more challenges (but they also have bigger IT staff). In other countries many of the payers are government centric or have a smaller number of payers to deal with.

Q: What financial consequences will ICD-10 have on the healthcare system?A: In the short term the financial consequences will be slower payments to care delivery organizations as systems are sync’d and they work through issues and bugs on the payer side. Unlike Meaningful Use, which primarily affected hospitals and clinicians’ internal systems and processes, ICD-10 is a “fully system challenge” which encompasses payers, providers, and ancillary institutions. Long term, though the financial consequences are likely to be positive because we’ll have more granularity of data and physicians can get paid more for complex services.

Healthcare Innovation is the creative adoption and usage of technology that works to improve the quality of healthcare by enabling personalised care models to predict when adverse healthcare conditions may occur and to better manage the health status of a patient real-time. Obviously the adoption and implementation of innovative tools will require significant changes to existing patient care models and organization restructuring to focus on personalised care.

Advancing technologies can enable better patient interaction, wellness management processes, and predictive analytics that focus on keeping patients healthy. As these technologies advance, so will the needs and methods that healthcare facilities have become accustomed to. So, what can your organization do to keep up with the times and use innovation to better their facility?

HCIs Senior Vice President of Innovation and Technology Solutions, John McDaniel, has a framework for how to establish and build an innovation team – from the Chief Innovation Officer to an innovation council, and eventually up to an innovation center.

1) CEO's and the Board

Before getting into the team that will be responsible for directing and managing innovation within your organization, it is important to keep in mind that a healthcare facility must first get their CEO, executive team and Board of Directors to see eye-to-eye with the idea. After all, the agents of change within a healthcare organization are ultimately the CEO and the Board of Directors.

Innovation is a change in the way an organization most likely has done business for a long time, and this change will probably cause some members of your staff to be skeptical. A change in the way an organization has done things may be faced with some resiliency, but the world is changing, technology is changing, and it is the responsibility of the CEO to make the decision for the better of their organization. Creation of an Innovation Strategy is essential and will assist the CEO and the Board with finding the right candidate to be their Chief Innovation Officer.

2) Chief Innovation Officer

When using innovation to influence a healthcare facility, one of the first things that must be done is establishing a Chief Innovation Officer. Innovation is a journey, not a destination, and the Chief Innovation Officer will be responsible with creating the roadmap for this journey, as well as being able to think outside the box with relation to how healthcare is traditionally delivered. This individual will be the internal champion at the executive level for innovation and change, and will have an understanding of the process of healthcare today, as well as what it’s going to evolve into.

In addition, the Chief Innovation Officer is going to need to be a great communicator who can work within a team concept. They will need to be able to use their understanding of information technology and the clinical process in order to work with constituents to create the roadmap for their innovation journey. It can be very challenging to find an individual who exhibits all of these qualities – however, there are a number of organisations who have found resources such as these who are doing an outstanding job in helping transform organisations into a new models of care. They cannot do this alone, however, which is why they will look to create an innovation council.

3) Innovation Council

An innovation council should consist of a combination of information technology, operations resources, planning resources, and clinicians. In addition, a good practice when forming an innovation council is to include at least a patient or two, because they will have a first-hand understanding of how they feel patients should be engaged, or how patients would like to be communicated with from a clinician (whether it be something such as TeleHealth or in person). Build a process or methodology around engaging with operational resources, clinical resources, and anyone else who is a constituent of your services.

Once your council has been assembled, you can begin to build a process where ideas are germinated and can be presented electronically. Your innovation council can then look at these ideas and begin to sift through them and decide whether or not they make sense based on your organisations strategic plan, or if they could be a current operational improvement, for example. They will then decide which ideas they will move forward with, and put together a high-level business case of what your organization will need to invest, what the change opportunity is, and how it can affect revenue. This innovation council will ultimately be the oversight for the organization in bridging operations with where the future of healthcare is going.

4) Innovation Center

The ideas that your innovation council has conceived and approved will need to be tested, and that is where the innovation centre comes in. Say, for instance, your innovation council has looked at 25 different projects, and needs to see how they will work. The innovation centre can build or test these new solutions, and can see exactly how they will impact the operations today, and how they will help to transform your organization into the future. The innovation centre is a lab, basically, that allows your organization to engage with partners to either provide a solution to a problem that you will be addressing or work towards the development of something completely new.

There are already some very good innovation centres out there, and they work to develop new products that can create a huge ROI in their organization, and have begun to take those and resell them. In some instances, the revenue that came from these resold technologies and applications was even greater than the annual revenue that was associated with patient care. They work with sophisticated, new concepts such as 3D printing, wearables, biomedical devices and their example is a great indicator of how beneficial innovation can be to a healthcare organization.

The Office of the National Coordinator for Health IT (ONC) has released a full document containing health IT policy levers on its website, giving various healthcare professionals access to different ways states leverage health IT to increase accountable care.

The document, entitled the State Health IT Policy Levers Compendium, reportedly lists nearly 300 different health IT policy levers and explains how states are able to use them to advance the use of health IT, interoperability, and system delivery reform.

For example, the document starts off by discussing how accountable care organizations (ACOs) can work to leverage different health IT policies. ACO payers such as Medicare or Medicaid within different states can require participants to use an interoperable EHR or participate in a health information exchange (HIE).

State entities contracting with providers for participation in an accountable care arrangement can align provider requirements with activities supporting interoperability. For instance, providers may be required to demonstrate they have adopted interoperable health IT or are participating in a health information exchange service in order to participate in the arrangement. Providers who can demonstrate adoption of interoperable health IT could also be provided with opportunities to earn greater rewards/access to shared savings under the terms of the arrangement.

These policy levers work by incentivizing different health IT capabilities. When the states implement certain health IT requirements, or create rewards for using different capabilities, they support the impactful adoption of health IT. All in all, this can help advance the triple aim of healthcare for better care, better spending, and better patient health.

“A health IT policy lever can be defined as any form of incentive, penalty, or mandate used to effectuate change in support of health IT adoption, use, or interoperability,” ONC writes in aCompendium overview. “This tool will help advance the country toward a delivery system with better care, smarter spending, and healthier people.”

The Compendium lists several different healthcare programs that can leverage health IT, and shows that many of them can help advance interoperability. For example, state appropriated funds can be focused on statewide HIE programs, or state lab requirements can include provisions regarding interoperability.

Some of the initiatives can also be leveraged to improve quality care and patient safety. State insurance commissioner policies can be focused on care quality through meaningful adoption ofinteroperable health systems. Additionally, state privacy and security policies can include provisions that “allow for more computable privacy while ensuring appropriate data is protected and shared.”

In addition to describing different potential policy levers, ONC lists the different states that have already embraced such levers. For example, when describing the state privacy and security policies, ONC reports that 16 states have already adopted that lever, including Alaska, Arizona, Arkansas, Colorado, Illinois, Iowa, Maryland, Michigan, Minnesota, Nebraska, New Hampshire, North Dakota, Rhode Island, Texas, Utah, and Wisconsin.

The compendium also has several limits. In lacking a full examination of how these different policy levers have worked for the states, the compendium is limited in giving a truly meaningful list of policy suggestions. Additionally, ONC acknowledges that its data sources are limited, and that state policymakers should consult other data sources in order to get a full view of how different policy levers would work to better their health IT use.

In all, the ONC hopes to continue to build on this document as the varied uses of health IT continues to grow. This will help ensure that states adjust their policies with each change that the industry sees.

“ONC expects to maintain the Compendium via periodic updates,” ONC writes in its document overview. “This initial launch will serve as a foundation upon which ONC will work with states to update and refine the information in the tool. It will also allow ONC to make improvements to the structure and possibly the format of the Compendium.”

Earlier this week, Andy Slavitt, Acting Administrator for CMS, told a group of attendees at the J.P. Morgan Annual Health Care Conference that meaningful use is on its way out.

“Now that we effectively have technology into virtually every place care is provided, we are now in the process of ending meaningful use and moving to a new regime culminating with the [Medicare Access and CHIP Reauthorization Act of 2015] (MACRA) implementation,” Slavitt told attendees. “The meaningful use program as it has existed, will now be effectively over and replaced with something better.”

The idea that meaningful use, a program which began in 2011 and aimed to incentivize or penalize physicians for adopting an EHR system, would be over, naturally caused many physicians to celebrate. Melissa Young, an endocrinologist in Freehold, N.J., and a member of the Physicians Practice Editorial Board, e-mailed a three word reaction to the news: “Hooray! ‘Nuff said.”

The AMA had a more formal way of celebrating this news. Of Slavitt, AMA President and CEO, Steven Stack, an emergency physician, told Beckers Hospitals Review in a statement: "He listened to working physicians who said the meaningful use program made them choose between following Byzantine technological requirements and spending more time with their patients. This is a win for patients, physicians and common sense."

In his speech, Slavitt talked about winning the “hearts and minds” of physicians back. Getting rid of meaningful use would undoubtedly help the federal agency achieve that goal, as evidenced by the rising number of docs who opted out of the program due to its stringent requirements. “The concept of meaningful use was always doomed to failure and it has been proven that there is no improvement in the quality of our healthcare delivery system and it has not reduced the costs of the provision of medical care,” Jeffrey Blank, a podiatric physician in Loxahatchee, Fla., and a member of the Physicians Practice Editorial Board, said via email.

Hold that Thought

Despite the excitement, Robert Tennant, health information technology policy director for the Medical Group Management Association (MGMA), says physicians should keep the champagne on ice. For one thing, they will still be judged on EHR and technical capability.

At the conference, Slavitt talked about MACRA, which authorized the creation of the Merit-Based Incentive Payment System (MIPS). MIPS will measure and compensate physicians on quality, practice improvement, cost, and use of technology. Within MIPS will be elements of meaningful use. Rather than rewarding physicians for using technology, MIPS will aim to pay them on using it towards improving their outcomes.

While Tennant says a reworked meaningful use is “potentially very positive,” the guidelines for MIPS are supposed to be released and finalized this year, which he notes could be a problem for physicians. “Payment under MIPS is supposed to take effect in 2019. If the traditional approach of using a two-year look back [to make those adjustments] is in place, it would mean reporting would begin in 2017,” he says. “If you look at the timing from a regulatory process, we’re concerned with how this would be accomplished.”

In essence, vendors would have to redevelop software around the guidelines, train customers, and practices would have to go live within the space of a year. Moreover, Tennant says if MIPS regulations are finalized in December of this year, they’d likely overlap with a new presidential administration.

“Any new administration, the first thing they do is typically put all pending regulations on hold and review them before they approve,” he says. Tennant also notes practices still have to be concerned over meaningful use regulations for 2016, including a full-year reporting period and the fact that Stage 3 of meaningful use is technically supposed to be mandatory in 2018.

“We don’t know what we are moving ahead to,” Tennant says. For practices, he advises to select software that fits their clinical needs and to not worry about “arbitrary and potentially changing” regulations. “Don’t focus on 2017 or beyond. We don’t know. The vendor doesn’t know.”

Even still, he is “cautiously optimistic” about Slavitt’s remarks. “We’re hoping CMS takes this opportunity to leverage MACRA to develop a program that is achievable and clinically relevant,” he says.

Blank is interested to see what lies ahead with government regulations, but is not as optimistic as Tennant. “I'm sure that many interest groups and the insurance industry will profit and doctors like me will continue to struggle,” he says.

A new report to Congress recommends steps to ease the secure sharing of patient information, paving the way for better coordination of care and improved patient outcomes. For example, the report recommends the creation of incentives to help overcome the "blocking" of data exchange or reluctance to participate.

Although the federal government has spent $31 billion so far on HITECH Act incentives for hospitals and physicians to "meaningfully use" electronic health records systems, Congress has been scrutinizing whether the investment has paid off in enabling the sharing of health information.

Some security and privacy experts say that while the report spotlights some of the key barriers to secure health information exchange, some of the concerns may be overstated.

For instance, Micky Tripathi, CEO of the Massachusetts eHealth Collaborative, says intentional information blocking among healthcare providers is generally not a widespread problem.

"There are bad apples in every group of humans, and healthcare providers are no exception," he says. "In my experience, malicious information blocking for competitive purposes is very, very rare, and is certainly not a big factor or even a major factor impeding health information exchange. The biggest impediment to information exchange up until now has been lack of demand. That has changed, and now that we have strong demand, we're seeing the market respond and I expect interoperability to grow dramatically over the next couple of years."

The report delves into the various technical, operational and financial challenges that the healthcare sector faces in achieving health information exchange. Among the issues related to privacy and security listed in the report are:

Misunderstanding about HIPAA and other privacy laws has led some to refrain from sharing information.

Applying privacy laws that were originally designed to address paper-based processes to today's electronic transactions has been problematic.

Designing electronic systems and rules to accommodate varying state privacy and security laws has been challenging.

Develop and enhance incentives that drive interoperability and data exchange, such as by focusing on delivery of coordinated care. For example, payers could decline to reimburse for medically unnecessary duplicate testing that could have been avoided if information was shared.

Set payment incentives to encourage health information exchange. Include specific performance measurement criteria and create a timeline for implementation.

Convene a summit of major stakeholders co-led by the federal government and the private sector to act on ONC's recently unveiled 10-year interoperability roadmap.

Information Blocking

Drilling down on the report's recommendations pertaining to payment incentives to help accelerate interoperability, the HIT Policy Committee specifically addresses the problem of information blocking, which involves healthcare providers refusing to share of clinical information.

Sometimes information blocking is related to misinterpretations and misunderstandings about HIPAA and other privacy laws, the report notes.

"There are many examples where misinterpretations of complex privacy laws inhibit providers from exchanging information that is permitted under HIPAA," the report notes. "Also, many providers do not fully appreciate that the HITECH Act gives patients the right of electronic access to their EHR-stored information. As the Centers for Medicare and Medicaid Services defines new payment incentives ... it should incorporate mechanisms that identify and discourage information blocking activities that interfere with providers who rely on information exchange to deliver high-quality, coordinated care."

Other Recommendations

The document also outlines some previous recommendations made by the HIT Policy Committee to ONC, including:

Provide guidance about best practices on the privacy considerations associated with sharing of individuals' data among HIPAA covered entities and other community organizations;

Guide efforts to establish "dependable rules of the road" and to ensure their enforceability in order to build trust in the use of healthcare big data.

Overcoming Privacy Hurdles

David Whitlinger, executive director of the Statewide Health Information Network of New York - the state's health information exchange - says privacy and security issues clearly represent some of the biggest hurdles to overcome before achieving nationwide data exchange.

"Privacy and security regulations vary across different states, and those difficulties are exacerbated even more in sharing sensitive health data, such as mental health, substance abuse, HIV, reproductive health, and information about minors," he says. EHR platforms don't easily support compliance with varying laws when data is exchanged, he notes.

But he points out that industry players are discussing the use of various technologies that "tag" sensitive information so that patients have more control over what part of their health records can be shared among healthcare providers. Also under discussion are policy issues such as "giving patients complete control over their data, so that they ultimately make the decisions about what subsets of data they'll share," he notes.

Tripathi says the biggest barrier to health information exchange, from a privacy and security perspective, "is the heterogeneity of privacy rules that any particular provider faces, which has a paralyzing effect on electronic information exchange."

For instance, in Massachusetts, HIV and genetic test results require consent from patients for each disclosure, he notes. "So even though a Direct [secure email] transaction doesn't require any special consent, certain types of payloads may trigger other consent requirements. So ... as a healthcare provider ... I will hesitate to send out anything until I understand which laws pertain and whether that data my EHR sends triggers any of those other laws."

What's Next?

Members of Congress now must decide whether to act on the HIT Policy Committee's various recommendations.

An aide to Sen. Lamar Alexander, R-Tenn., chair of the Senate Committee on Health, Education, Labor and Pensions, says in a statement provided to Information Security Media Group: "Sen. Alexander is focused on making electronic health records something that physicians and hospitals look forward to instead of something they endure, and he looks forward to hearing what recommendations [the HIT Policy Committee] outlined in [the] report."

While the report notes that steps could be taken to begin implementing various recommendations within the next six months, some healthcare IT experts say it could take years for comprehensive health information to be securely and readily exchanged among healthcare providers by using health information exchange organizations and EHR systems.

"Having accomplished the significant goals of greatly expanded EHR adoption and baseline interoperability via Direct, but also having alienated almost the entire health care provider community by overreaching for the final, Stage 3 version of its regulations, the Meaningful Use programs will be phased out by the end of 2016," the organization maintained in a public statement. "Providers are particularly worried because the requirements of Stage 3 MU do not align well with MIPS and MACRA, the new rules under which Medicare will pay for value and performance, rather than for volume of care."

DirectTrust sees things playing one of two ways.

"It may occur as a result of massive defections by providers willing to face fee schedule penalties rather than spend more resources on health IT that doesn’t add value to their practices and hospitals, it continued. "Or, it may happen as a result of Congressional action, or because CMS and ONC see the hand-writing on the wall and scale down and bow out gracefully."

The organization's prediction echoes the sentiments of Beth Israel Deaconess Medical Center CIO John D. Halamka, MD, MS, who less than a month ago asserted that meaningful use had served its purpose and ought to give way to Medicare Access and CHIP Reauthorization Act (MACRA).

Similarly, both DirectTrust and Halamka consider the lofty aims of Stage 3 Meaningful Use are sufficient cause for moving away from the federal program.

Elsewhere in its health IT predictions for 2016, DirectTrust expects patients to take on a more significant role in ensuring the electronic exchange of their health data:

Patients will have greater access to their clinical records, and they will be able to more freely and easily move those records whenever and to whomever they choose. Health care consumers will take as their right control of their own health information in much greater numbers. The corresponding willingness of provider organizations to permit this patient engagement — and to view it as positive and productive to attaining better health outcomes — will also become more evident across the U.S.

The consequence will be a freeing of data and an increased focus on patient-facing applications although it may not go as smoothly as desired.

"This will not happen linearly; rather it will grow explosively, and then suffer hiccups and setbacks as the privacy and security risks of such systems are first exposed, and then dealt with. But it is going to happen," the group added.

This is likely to tie in with another of its predictions — the coming to the fore of health data security and privacy in 2016.

"The cost of data breaches in health care is simply too high to be tolerated," DirectTrust stated. "As use of electronic health information exchange soars, we will experience a corresponding rise in concern about and actions taken to mitigate the risks of exposure of both data at rest and data in transit. Parties involved in electronic data exchanges will insist on more and more rigorous certification, accreditation, and audit of security and identity controls as a first condition of participating in data sharing."

In its remaining predictions, the organization anticipates a movement toward greater interoperability on the part of federal and state agencies as well as a growing reliance on Direct exchange for enabling the secure and interoperable movement of health data between and among providers for the purposes of care coordination.

EHR and practice management (PM) systems come with built-in reporting capabilities but digesting all that information can be overwhelming. However, leveraging the power of Excel to sort and manipulate the data stored in your EHR can help you spot trends faster and implement steps to drive revenue growth.

“Excel is a great way to slice and dice your practice management data so you can really use it to improve,” says Nate Moore, CPA, MBA, an independent consultant and coauthor of “Better Data, Better Decisions: Using Intelligence in the Medical Practice.” “Excel allows you to filter, trend, and get your arms around reams of data.”

Excel offers an interactive tool called pivot tables that allow users to quickly sort, filter, and manipulate data, says Moore, who moderates the Excel Users Medical Group Management Association Community, an online resource for practice administrators. It gives users much more flexibility than an EHR, which typically offers a limited number of canned reports.

For example, your PM system can probably produce a general report on your collection rates at the front desk at the point of service. But a pivot table would allow you to slice that data in a variety of ways, such as individual employees’ collection rates by location or time of day.

In addition, you can connect Excel to the server where your data is stored so you are always working with the most current numbers, says Moore. That allows you to quickly run the same types of reports with updated data.

“A lot of practice administrators don’t run reports as often as they’d like because they take so much time to run and analyze using the PM and EHR,” says Moore. “Using Excel streamlines the process, making it more likely that reports will actually get produced.”

Moore offered a few examples of how pivot tables might be used to dig deeper into financial reports and zero in on potential problems:

1. Focus on overdue accounts. A general report on aging accounts receivable from your PM system might contain hundreds of pages, making it difficult to focus on specific trends. Exporting that data into pivot tables allows you to zero in on problem areas, such as claims overdue by 60 days categorized by insurer.

2. Gage productivity. If your compensation system is based on productivity, you can look at work relative value units by individual providers or during certain time periods.

3. Monitor workflow. Larger practices can monitor and compare activity at different locations. For example, how many patients did one employee register at a specific location vs. another employee at a different office? How many appeals or claims did each individual employee process at each office?

4. Analyze your patient base. Using a basic pivot table, you can see all of your new patients in a given year categorized by month of visit, referring physician, diagnosis code, insurance, or clinic location. Analyzing the data reveals trends, such as how many patients each physician saw in each year over the past five years.

5. Group data. You can group data to spot referral trends. For example, how many commercially insured patients did one group of referring physicians refer to each individual provider in your practice, for each of the past five years?

Several weeks following the implementation of the ICD-10 code set, the progress of the transition appears to vary according to size of the practice. While many large practices are reporting success with the transition, some smaller ones are reporting difficulty.

According to a blog post by the Coalition for ICD-10, many of the group’s members -- which happen to be larger healthcare providers -- are reporting great success with the transition. Many, like Centegra Health System, credit this success to the ample time for preparation they received.

“Centegra Health System was prepared for a smooth ICD-10 transition after two years of careful planning. Our information technology systems have been updated and our educational plans were deployed to help with the initial roll-out,” said Centegra’s Executive Vice President, Chief Financial Officer, and Chief Information Officer David Tomlinson.

Additionally, some coalition members stated that their success on October 1st is due in large part to their early implementation of the code set.

“Northwest Community Healthcare’s transition to ICD-10 has been smooth. This is due, in part, to our early clinical rollout of ICD-10 with our Epic Go-Live date of May 1, 2015,” said President and Chief Executive Officer of Northwest Community Healthcare Stephen Scogna.

Other members of the coalition, such as insurer Blue Cross Blue Shield of Michigan, reported a few bumps in the road amidst a generally smooth transition.

““BCBSM’s ICD-10 implementation went very smoothly. Call center volumes and overall inquiries are very low. Professional and facility claims are processing as expected. A few issues noted, which we are resolving, but nothing major to report,” the insurer said.

BCBSM also reported that it was the first private insurer to reimburse the hospitals it serves.

“Received kudos from our hospitals stating that BCBSM was the first payer to pay ICD-10 claims and these claims are paying as expected. Hospitals are not reporting any major issues. Other Payers (Priority, Cigna, Aetna) are reporting the same experience in that they are not seeing any major issues.”

However, this success is in contrast to what some other smaller providers are reporting. The impact of ICD-10 on smaller providers is a little bit more weary as these providers have fewer resources to work with.

For example, Linda Girgis, MD, FAAFP, told EHRIntelligence.com that due to how small her practice is -- she and her husband are the only physicians in the family practice -- its workload has grown much larger. This work includes changing patient problem lists from ICD-9 codes to ICD-10.

"The doctors are doing it right now," she says. "I'm doing it as I come across different patients, but definitely it's adding time on to the workday."

Smaller practices are especially affected by ICD-10 troubles because much of their revenue comes from the Centers for Medicare & Medicaid Services (CMS), and the agency has been reportedly unreachable throughout the transition.

"My biller tries to call every day. Since October 1, they have messaged that they are down due to technical difficulties so it's impossible to get through to any person there,” Girgis said.

Not receiving CMS payment is problematic for small practices like Girgis’ because those payments may amount to almost 30 percent of hospital revenue. While a larger hospital, like those mentioned above, may be able to do without 30 percent of its revenue for a month or two, this kind of issue could be potentially detrimental for a practice like Girgis’.

"Big organizations, hospitals, and groups can go a few months without 30 percent of their reimbursement coming in. But for small practices, that can be devastating," argues Girgis.

CMS set a timeline for rolling out ICD-10 payments, stating that those claims would be reimbursed within the first 30 days of the new code set. As that 30-day timeline draws to a close, small practices will be waiting to see if their claims are reimbursed.

EHR interoperability has been brought to the forefront lately as various health organizations and government agencies push for nationwide health information exchange. Furthermore, as integrated healthcare and care coordination become fixtures in the healthcare delivery industry, interoperability of systems between different kinds of practitioners shows itself to be critical.

A recent study by Maribel Cifuentes, RN, BSN, Melinda Davis, PhD, Doug Fernald, MA, Rose Gunn, MA, Perry Dickinson, MD, and Deborah J. Cohen, PhD, discussed how EHRs operated in 11 practices that were integrating the delivery of primary and behavioral healthcare. The researchers found that when behavioral health and primary care begins to integrate, the two kinds of practitioners brought separate EHR systems with them. This caused challenges and subsequent workarounds and solutions associated with EHR interoperability.

The study took 11 integrated practices in the Colorado area and gathered data regarding how EHRs worked for their needs, the challenges practices faced, what kinds of workaround strategies practices developed, and what kinds of long-term solutions the practices identified in order to promote care coordination over an EHR.

One of the challenges many of the integrated practices faced was that the EHRs were not necessarily designed to collect a certain kind of data. For example, in a primary care facility that hired several behavioral health counselors (BHCs), the facility’s EHR may not have been conducive to collective behavioral health data.

Third, many EHRs were not interoperable with each other, hindering primary care physicians and BHCs from working together in delivering coordinated care. The EHRs were also not compatible with tablet devices that were used to collect behavior health information in the waiting room prior to appointments. These tablets were used to present questionnaires that would provide behavioral health data. However, the lack of interoperability between these devices and EHRs made it so the data collected in the questionnaire could not easily be uploaded into the EHR.

The study reports four workarounds that were developed in the face of these challenges. First, as stated above, when the primary care and behavioral health practices first integrated, the physicians often had their own separate EHR systems. In order to make sure both systems had patient information, physicians had to manually enter the data into both EHRs. While this method may have been effective in ensuring patient information was stored in both EHRs, it was not particularly time or financially effective.

Second, medical assistants had to manually scan printed documents into EHRs. While this method may have also been effective, it presented several time and financial issues. Furthermore, the scanned documents were often harder to find in the EHR, hindering the physician from delivering care to patients in a timely manner.

Third, practitioners relied on patients and other physicians to recall patient information. This workaround was not effective because patient and physician memory was neither reliable nor accurate. One physician reported having to recall patient information that was told to him several weeks before meeting with the patient. Due to the amount of time that had passed since he had last discussed this patient, he was unable to determine what kinds of services the patient needed. This resulted in the patient taking tests that had already been administered.

Fourth, practitioners employed “freestanding tracking systems,” such as spreadsheets, that were not a part of the EHR. For example, one practice stored information regarding adolescents taking selective serotonin reuptake inhibitor medications in an Excel spreadsheet. Although this was widely used amongst the practice, it took enormous effort from practitioners to maintain, and the information on the spreadsheet was not easily integrated into the EHR.

By the end of the study, researchers observed that practices began moving past workarounds and toward more long-term solutions to their challenges in order to make their integrated practices more sustainable in the future. The researchers noted that these solutions were created by each practice’s own HIT teams and required their own funding. Three key solutions amongst the participating practices emerged.

First, many practices created their own customized EHR templates. These templates existed within their pre-existing EHR systems, and simply added more fields for data entry that would be more suitable for practitioners’ needs. However, developing these templates was an arduous task.

“Creating customized EHR templates was time consuming and required dedicated HIT staff working collaboratively with BHCs and primary care providers,” the researchers reported. “Practices that did not have access to these resources were not able to create customized templates as readily, or had to pay EHR vendors to do so.”

Second, some practices purchased EHR upgrades and reported several improvements from doing so, including increased interoperability, enhanced reporting templates, and more interfaces for integrating primary and behavioral health care.

However, EHR upgrades were considerable financial investments for practices. Practices were not allowed to upgrade their EHRs using the money allocated to them by participating in the study, so the upgrade needed to be a part of the individual practice’s investments. This financial burden made it so only five of the 11 participating practices were able to upgrade their EHRs.

The final emerging solution was the union of two EHRs. At the start of the study, four of the 11 participating practices were using two different EHRs -- one for behavioral health care and one for primary care. By the end of the practice, three of them were in the midst of merging those two EHRs, and one had built an interface that extracted data from multiple EHRs and stored the data in one place. While these solutions were quite complicated and costly, they were the most effective in overcoming interoperability challenges.

Despite the advances these practices made, the researchers maintained that integrated providers may still face hurdles in the future.

“EHR systems are not yet optimally designed to meet the needs of practices integrating behavioral health and primary care,” the researchers stated. “Our study found that EHRs generally lack features essential to support key integration functions such as documenting and tracking longitudinal data, working from shared care plans, and template-driven documentation for common behavioral health conditions such as depression.”

The researchers provided guidance on how to improve EHR use in integrated care situations, stating that perhaps systems need to start being designed for integrated care, as should different incentive programs.

“In the future, HIT systems should be intentionally designed, in cooperation with clinicians; to support and enable these integrated care functions, as well as the different modes of communication and care coordination tasks that occur between multi-professional members of integrated teams,” the researchers maintained.

Furthermore, the researchers stated that more financial incentives should be provided to allow practices to make these kinds of changes. Although several EHR and interoperability incentive programs exist, none of them provide incentives that would help practices change their EHR systems to make it more usable in an integrated practice.

EHR use presents many healthcare benefits, including coordination of care and increased patient engagement. However, , the lack of EHR and health IT interoperability is posing a serious threat to other healthcare initiatives, according to a recent report published by the American Hospital Association.

The report, entitled Why Interoperability Matters, discusses the various aspects of the healthcare industry and care delivery that are negatively impacted by a lack of interoperability. Among those aspects include care coordination, patient engagement, and public health and quality measures reporting.

Care coordination

The exchange of health information is critical for the coordination of care, according to AHA. When patients receive care from multiple different providers, physicians should be able to securely send relevant patient information to the practicing physician. However, that tends not to be the case because EHR systems are not interoperable and cannot exchange information.

Furthermore, care coordination and successful interoperability are vital for provider finances. As accountable care organizations and bundled payments continue to grow more prevalent, the AHA maintains that interoperability and the ability to see all of the care a patient in receiving is crucial in preventing unnecessary treatment.

Patient Engagement

Patient engagement and the shared decision-making between providers and patients is critical in achieving the aims of the healthcare industry, the authors of AHA report maintain. Further, patient engagement is a central part of federal regulations on using an EHR. However, the agency states that many patients are unable to access their electronic health information, hindering the practice of patient engagement.

“The real problem is that the vast majority of patients cannot access their health information in a holistic, meaningful way. Instead, they must go to each of their providers’ patient portals and download unintegrated data. Making sense of this, particularly for patients with multiple chronic conditions who frequently have many health encounters a year, is difficult,” the report states.

Public Health and Quality Measures Reporting

EHR use also provides the opportunity for enhanced public health reporting. Because patient data is aggregated on one, electronic system, healthcare professionals can track healthcare trends and analyze information about population health. But without adequately interoperable systems, that process is significantly hampered.

“Hospitals are happy to report this data to improve public health but must contend with a wide variety of reporting formats and transmission technologies to do so, including faxing, mailing, e-mailing, web forms and secure file transfer protocols,” report reads.

Healthcare providers have created a few solutions to this interoperability problem, including interfaces and health information exchanges.

Interfaces are programs that allow a facility’s EHR to pass along information from one system to another, yet practices face challenges when using interfaces for more than one provider.

“...in health care, each interface currently is like a snowflake: it must be built to meet the unique requirements between two providers and cannot be reused,” the authors explain.

Because practices would need to adopt multiple interfaces, they are not always a financially stable solution to interoperability.

Like interfaces, health information exchanges (HIEs) have presented themselves as potential solutions to interoperability problems. Although HIEs can be successful in securely transmitting health information between providers, they too are quite costly. Furthermore, AHA explains that many HIEs are installed via federal grants, and that when the grants run out, many practices are unable to maintain their HIEs.

Health IT standards need more specificity

Although there are a set of standards identified for the use of EHRs and other health IT, they are not specific enough to be effective, the authors note. Creating uniformity in how data is collected and stored on an EHR, however, would be a drastic step forward for interoperability, the report states. Increased health IT standards would cause data to be input in the same way across the healthcare delivery spectrum, making information sharing more feasible.

Although the authors acknowledges the potential that health IT standards have in increasing interoperability, the agency maintains that much work in defining those standards and developing other platforms needs to be done before the industry can achieve nationwide interoperability.

Although the Office of the National Coordinator for Health IT (ONC) recently released itsInteroperability Roadmap, the American Academy of Family Physicians (AAFP) does not believe that is enough to achieve nationwide EHR interoperability in a timely manner.

In a recent letter addressed to National Coordinator Karen DeSalvo, MD, MPH, MSc, AAFP’s Board Chair Robert Wergin, MD, FAAFP expressed his and the organization’s dismay at the slow progress of nationwide interoperability.

“Our members and the AAFP are very concerned with the very slow progress toward achieving truly interoperable systems. Furthermore, we strongly believe there is need for increased accountability on industry and decreased accountability on those who are using their inadequate products,” wrote Wergin.

According to Wergin, care coordination, patient engagement, and population health management all need greater support through increased interoperability. However, at the rate the healthcare industry is moving with regard to interoperability, those goals are not expected to be achieved soon. To change this course, Wergin says the industry needs more action rather than more planning. Additionally, providers and organizations that are playing their parts in increasing interoperability need more support.

“We need more than a roadmap; we need action. First, it is our belief that without significant changes in the way health care delivery is valued (e.g. paid) then it will not matter how many standards are created, how many implementation guides are written, how many controlled vocabularies are fortified, or how many reports are created; we will still struggle to achieve interoperability. Any roadmap for interoperability needs to ensure payment reform toward value based payment, in addition to the technical work. This aligns the health care business drivers to the achievement of true interoperability.”

Wergin argued that certified EHR systems are a contributing factor for this slow growth toward nationwide interoperability. In 2007, he said, the AAFP was responsible for creating a set of standards for healthcare summary exchange. However, despite the adequacy of those standards, Wergin reported that practitioners still experienced difficulty in exchanging information due to incompetencies of EHR systems. Because the EHR systems cannot interpret the data that is being exchanged between systems, physicians are finding themselves manually inputting data from one system to another.

“Instead, physicians must view the documents on the screen, just as they would a fax, to find the important information. Then they must re-key that information into their EHR if they want to incorporate some of the summary information into the patient’s record,” Wergin explained.

Wergin described an urgent need to transform interoperability. If practices are expected to achievemeaningful use and other incentive-based models, interoperability needs to be a high priority for the health IT industry.

“Everyone including technology vendors, hospitals, health systems, pharmacies, local health and social service centers and physicians, must come together as a nation to achieve the interoperability levels laid out in this roadmap at a more rapid pace,” Wergin wrote.

Comparing the push for interoperability to President Kennedy’s push to get to the moon, Wergin states that the health IT industry should be able to achieve its goals in the same 10-year timeframe that Kennedy did. By 2019, Wergin stated, the entire healthcare industry should be using completely interoperable systems.

“We should be much closer to our goal and it should be accomplished within ten years (2019),” Wergin wrote. “The AAFP is dedicated to continue our work to achieve interoperability which is fundamental to continuity of care, care coordination, and the achievement of effective health IT solutions.”

Epic Systems is in the driver's seat compared to other ambulatory EHR vendors and poised to take control of an even larger portion of the outpatient EHR market, according to a recent survey of more than 170 ambulatory care facilities.

Conducted by peer60, the report shows Epic to control close to 20 percent of the ambulatory EHR market several points ahead of its main competitor Cerner Corporation, which owns less than 15 percent.

The authors of the report base their predictions for Epic's growth on the perceived market dominance of the Wisconsin-based EHR vendor — that is, "mindshare." Epic and Cerner are neck and neck among ambulatory care facilities in this area, hovering around 32 percent.

"As has been the case in past years, Epic’s and Cerner’s aggressive positions will continue to gobble up pieces of the ambulatory pie currently occupied by vendors that have struggled to stay relevant in this space," the report states.

Also likely to make gains are athenahealth and eClinicalWorks whose mindshare ranges between 14 and 20 percent:

The other half of the market share and mindshare story and equally impressive is athenahealth’s and eClinicalWorks’ significant mindshare figures at approximately eight and five times their current market share in the overall ambulatory EHR market, respectively. This indicates these vendors are finding significant ways to positively connect with providers.

According to the authors, the disparity between market share and mindshare indicates a need for EHR vendors to improve their standing among ambulatory care providers, a caveat being that EHR vendors focusing on independent facilities have less to lose because many ambulatory centers base their EHR selection on hospital EHR selection.

For these independents, Epic and Cerner trail NextGen based on market share, the latter holding close to 20 percent of the marketplace. As for mindshare, NextGen's prospects are not good "considering they occupy no space in the future plans of independent ambulatory providers," the authors contend. Meanwhile, eClinicalWorks is set to make major gains among these ambulatory care settings well ahead of both Epic and Cerner.

Factoring in to future ambulatory EHR selections will be EHR vendor recommendation scores from providers. On average, ambulatory providers are more likely than not to recommend their current ambulatory EHR technology to others — 6.2 out of 10. The scores for individual EHR vendors is not made public, but five vendors scored above the 6.2 mark with one scoring as high as 9.3.

What will likely influence ambulatory EHR selections are solutions to the top challenges for provider EHR users. The top EHR challenges are missing EHR functionality (55%), lack of EHR usability (42%), and support of a practice's strategic objectives (30%).

Despite these responses, the ability of EHR vendors to make inroads in the ambulatory care setting will be difficult. A vast majority of respondents (85%) are not actively looking for EHR replacement technology. This is the case for both hospital-owned and independent ambulatory facilities.

As the transition to electronic health records continues, we’re beginning to see how the use of EHR software can transform the ways that care is provided, as well as the quality of that care. With increased adoption, EHR software is becoming an integral part of the healthcare experience for both providers and patients.

In the U.S., changes to HIPAA regulations and incentives for providers have had tremendous impact on the landscape of electronic health records. As EHR software matures, interoperability and ease of access, improved patient portals, and a move toward cloud-based solutions are going to be some of the biggest trends in electronic health records.

One of the key features of electronic health records is ease of access. Ideally, both providers and patients will be able to utilize EHR software in ways that maximize access to information and create smoother workflows. That also extends to full interoperability between systems.

Ideally, practitioners will be able to quickly share information with other healthcare providers inside and outside their organizations, streamlining care for patients, and making sure that practitioners have full access to health records at all times. Improved interoperability also has long-term benefits outside of individual patient interactions. For example, researchers could use pools of patient records to identify trends, or use of the large datasets that improved EHR software interoperability would provide for large scale real-world studies of treatment outcomes.

Along with interoperability comes the need for improved patient access to their own electronic health records. The United States Congress enacted regulations in 2009 to provide financial incentives to encourage adoption of EHR software, and HIPAA regulations also require that electronic health records also allow for patient access to stored data. According to a 2015 report, the number of people accessing their electronic health records via a patient portal is on the rise. In 2014, 38 percent of Americans had access to their health information, an increase of more than 33 percent over the previous year. Of those patients who had access, more than half—55 percent—had accessed information contained in their medical record. Clearly, the trend is toward improving and increasing patient access to personal medical information via continued development and improvement of EHR software.

Like most other modern technologies, the shift toward mobile devices is also playing a key role in shaping EHR software. Consumers are more comfortable using mobile devices, which makes cloud or mobile EHR more important for practitioners and EHR software providers.

But there are also many upsides to cloud EHR solutions for healthcare providers, including reduced costs, better scalability and improved data security. Without the need for large onsite IT departments to manage software and hardware, cloud EHR software allows healthcare providers of all sizes to focus resources on patient care, which is in the best interests of providers and patients alike.

Healthcare is changing, and electronic health records will continue to be a driving force in the evolution of the industry. We’ve already seen some of the tremendous benefits that EHR can provide, and look forward to the innovations in EHR software that will empower healthcare providers to offer better, more streamlined care to their patients.

When it comes to online training, I often find that many participants have reservations about online courses. Many think it will be hard to focus and they won’t learn as much as an in-person class. I can relate – when given the option to take an online class versus an in-person class, I used to always pick the latter. That was before I realized the benefits of convenience that online training offers.

After taking and also teaching many online training sessions, I’ve gathered a few tips to help you get the most out of your online training experience.

1. Tell coworkers you are in a training session.

The idea here is to minimize the amount of distractions that can occur during class. Set expectations in advance by letting coworkers know you may take longer than usual to respond to requests during the training session. Try setting up automatic email replies that alert others you are in a training session and will reply as soon as possible. It may also be a good idea to block off your online calendar so coworkers will know you are attending a class.

However, if you need to leave the training session to attend to an urgent work matter, let the instructor know.

2. Log in to your online training course from a different location.

If your regular work environment is particularly distracting, minimize distractions by attending training from a different location. Whether this is from a conference room or your home (assuming it’s quieter there), relocating can be extremely beneficial to ensure you absorb the information presented during class.

3. Check your internet connection before class

A strong and reliable internet connection is key to your success in an online training class. This will help you hear and see the presentation as designed, as it is presented. A wired connection is almost always preferred over Wi-Fi. If that is not possible, ensure the Wi-Fi signal is strong prior to class so you don’t experience technical difficulties.

4. Don’t be shy! Participate in online class dialogue.

Participating more than you would in an in-person class can help you stay engaged with the online class material. Try regularly asking questions or try answering questions posed by the instructor, even if this isn’t your typical approach (don’t worry, no one can see you online). The more engaged you are during online training, the more likely you are to retain the material and remain focused throughout the duration of the class.

5. Speak up when you need help.

During in-person classes, the first indication that a student may need help is a furrowed brow or a confused look on a his or her face. With online classes, however, the instructor usually doesn’t have visual cues alerting them when to intervene. Speak up if you don’t understand a concept or have a question! Otherwise the instructor will assume you are comprehending the information as intended.

Is it time to go a new route with your EHR system? Before you decide yes or no, weigh the positives and negatives.

Only 34 percent of physicians are satisfied or very satisfied with their EHR systems, according to a recent survey conducted by the American Medical Association and AmericanEHR Partners. Another survey published in the American Academy of Family Physicians' journal, Family Practice Management reported that only 39 percent of respondents who changed EHRs were pleased with their new system.

The results of these surveys outline how the decision to change EHR systems or not is a difficult one. After all, it's a significant financial investment and staff have spent a lot of time learning how to implement and use their system. If you change, your practice will have to foot these costs all over again. In addition, you face the potential loss of data and problems with data migration.

HANG IN THERE

"A well-designed EHR should be physician centric, specialty specific, and serve as a tool for the physician to document a patient's visit," says John Pitsikoulis, managing director of Berkeley Research Group, LLC, a firm located in Hunt Valley, Md. "The EHR must also meet the practice's business needs, including the revenue cycle. When an EHR doesn't align with a practice's specific day-to-day work flows, it makes the physician's job more difficult by increasing [his] administrative and compliance workload. By negatively impacting the physicians' time, patient care is impacted."

While it's tempting to want to replace something that doesn't meet your expectations, under certain circumstances you may want to give it more time. "First, determine if your current system offers enough functionality for managing your practice and achieves meaningful use requirements set forth by CMS. Also, verify that the vendor's strategy for future enhancements outweigh any short-term disadvantages," Pitsikoulis advises.

If your practice likes some of the core features and functions of the system, already developed specialty-specific templates, and can live with navigating through notes, orders, and prescribing without overwhelming frustration, living with the current system makes sense at least for the short term, Pitsikoulis continues.

One common complaint of physicians is that they have become data entry clerks at the expense of patient care. "This is a common physician finding, regardless of the EHR system," Pitsikoulis says. "But changing systems could result in the same functionality."

The truth of the matter is that a lot of systems aren't lacking in functionality and can be beneficial if you take the time to learn how to use them, says Eagan, Minn.-based Derek Kosiorek, principal consultant of Medical Group Management Association (MGMA) Healthcare Consulting Group. One way to determine if this is the case at your practice is by finding out which physicians successfully use the EHR. If it's more than half, then the EHR isn't the problem and other doctors need to invest more time in learning to use the system more efficiently. See if those doctors can assist others in learning the system.

TROUBLESHOOTING

Before throwing in the towel, see if the vendor is willing to work with you on resolving issues. Work with the vendor to identify each problem and then ask if the vendor can offer a solution, says Mechanicsburg, Pa.-based David J. Zetter, founder and consultant at Zetter HealthCare.

If it is more difficult to order tests or enter information into the medical record than before having the EHR, something is wrong, says Ann Arbor, Mich.-based Joette Derricks, owner of Derricks Consulting, LLC. The EHR should streamline the work flow, not add more steps. If employees are printing out information and still depending on paper, something is probably not set up properly. Open communication is critical to identify and resolve problems.

Making some enhancements to the EHR documenting process with voice recognition software, streamlining the physician coding function with built-in coding software, and optimizing the EHR features and functions with templates, could provide some shortcuts that make an EHR more desirable, Pitsikoulis says.

However, be cautious when adding these enhancements. Engage consultants with operational, technical, and coding compliance expertise to integrate the physician's work flow with the technology. "Otherwise, you might end up with similar performance dissatisfaction with the next tool," Pitsikoulis says.

PULL THE PLUG

Sometimes, despite your best efforts, you may want to call it quits. Poor technical support is a key reason to get a new vendor. "Oftentimes, marketing staff is very accessible early on and then a year after implementation you can't get a basic question answered," Derricks says. In this instance, it's time to move on.

Furthermore, if the vendor does not update its software to facilitate new medical technology or contractual payment updates, that's problematic, Derricks says.

In addition, if an EHR lacks the ability to integrate with other software such as laboratory tests, diagnostic tests, practice management systems, and so forth, it's probably time to start anew, adds Zetter. Other reasons to say "adios" are if staff cannot effectively use the system, if it impedes patient care, or if it's just too costly to continue to use.

Or, if information is consistently incorrect because the system is set up poorly, or you're finding bad data, start over, Kosiorek says.

MAKING A DECISION

Even though EHRs may pose a lot of challenges, their ability to exchange health information electronically has enormous benefits. EHR capabilities, such as electronic prescribing, improve patient and provider communication, while providing for the patient.

If you're unhappy with your EHR, it's important to understand what went wrong in your last EHR selection so you don't repeat those mistakes. Perform a needs assessment by categorizing the current deficiencies and determine if these can be improved. If not, then it's time to begin the process of selecting a better EHR.

CHOOSE RIGHT THE FIRST TIME

After incorporating a new EHR system, many physicians will have to change the way they've done their job since beginning their careers. "They are being asked to take information in their paper chart, shuffle it like a deck of cards, and then have it presented to them in various places on a computer screen," says Eagan, Minn.-based Derek Kosiorek, principal consultant of the Medical Group Management Association Healthcare Consulting Group. "Then, they have to get used to navigating to where the information is relocated. This can be difficult, as some vendors in the early days of creating EHR software didn't design it in the most user-friendly way for physicians."

Fortunately, this is evolving, but as a result it's leaving some physicians wondering whether to stick with the old or upgrade to something new.

Whether selecting an EHR for the first, second, or third time, the selection, implementation, and integration of work flow with new technology is complex, and requires continuous process improvement. "Usually, the need to make a decision and begin the implementation process gets in the way of a complete and thorough understanding of the technology and the practice's needs," says John Pitsikoulis, managing director of Berkeley Research Group, LLC.

When beginning the process of selecting an EHR, a practice's providers and staff should have an opportunity to "kick the tires." Yet, very few often do, says David J. Zetter, founder and consultant at Zetter HealthCare. Trying out a potential system gives users a chance to determine if it's a good fit. For example, they should ask the vendor "How will the EHR work with the practice's way of documenting a patient encounter? How will the practice management part of the software suite work? And, what is the reporting like?" And to make sure that the EHR will fit your unique needs, talk to other same-specialty practices that use the same system.

In addition, practices often fail to thoroughly check references. "Don't accept only a few names as references," Zetter says. "Ask proper questions of many practices that have implemented it, such as 'Would they choose it again? Why or why not?'"

Q: With the new 2016 CPT codes, I no longer see the 31620 Diagnostic Bronchoscopy code I used to use with EBUS (Endobronchial Ultrasound). How do I report a bronchoscopy with fine needle aspiration using EBUS now?

A: So, code CPT 31620 — the code that was used along with all diagnostic and therapeutic bronchoscopies when EBUS was performed — has been deleted. One of the three new codes added to the respiratory section, 31654 is the code that you will now use with other diagnostic and therapeutic bronchoscopies, if those codes are on this list (the list appears as a parenthetical note under code 316540): 31622, 31623, 31624, 31625, 31626, 31628, 31629, 31640, 31643, 31645 and 31646.The old combination 31620 and 31629 for Bronch with FNA and EBUS — is now 31629 and 31654.

MODIFIER 58 or MODIFIER 79

Q: A patient with end-stage renal disease (ESRD) is taken to the operating room for creation of arteriovenous (AV) fistula (90-day global) in anticipation of dialysis. (As you are most likely aware, the fistula must mature for a period of time before it may be used).

Unexpectedly, the patient's renal status declined even further and the patient was not able to wait for the AV fistula to mature, so he was taken to surgery only a week later for a dialysis catheter placement.

We are struggling with modifier 58 vs. modifier 79. (I know, it's usually a question of modifier 58 vs. modifier 78) Some coders believe it should be modifier 58 because the reason for the surgery is the same: ESRD with need for dialysis. Some of our coders believe it should be modifier 79 because it is unrelated to the previous surgery, only related to the disease process and the second surgery was even a separate anatomical area.

A: Great question but you may be over-thinking this. You'll likely be asked to submit the documentation to the payer with either of these modifiers — so they will surely have an answer for you — you can count on that.

The purpose of both modifiers 58 and 79 is to underscore either the character of or the distinctness of the second procedure.

Modifier 58 gives three broad conditions that you may need to indicate: a) Staged (planned), b) more extensive, and c) therapy following a surgical procedure. Your scenario fits none of those.

Modifier 79 simply says "unrelated" to the original procedure. And "related" can mean a lot of things. The CCI edits do not link the codes to which you are referring — so there is no bundling. It is unlikely that these would hit an exclusion edit in payer software in the first place.

As to the reason for the surgery being the same — there is truth in that — but they are separate surgeries, unrelated to one another in a surgical sense. Given your scenario, I'd go with modifier 79.

FOURTH-YEAR RESIDENTS

Q: Can licensed fourth-year residents work in urgent care without supervision? Will CMS allow full payment for non-board-certified fourth-year residents for their patient care practice with no supervision? Is it a good or legal practice for an urgent care to hire solely fourth-year residents doing all the patient care?

A: We can't give legal advice. So you may need to share this question with others. From a coding and billing perspective there are some options here:

Residents are licensed medical professionals, MDs. There is a large body of regulatory guidance pertaining to supervision of residents in a teaching setting — very little outside the teaching setting. This is due principally to payments made to attending physicians and the need to make distinctions between which provider did what.

In your scenario, residents can apply for billing privileges and become credentialed to the extent possible with a given payer. There may be payer-specific limitations related to board certification but residents have been "moonlighting" since before there was a Medicare.

If a resident is not supervised by another credentialed physician, direct billing would be the only way to go to facilitate professional billing. If there were another credentialed physician onsite, CMS does allow one physician to bill incident-to another.

The American Health Association (AHA) is the latest industry group to share its recommendations for changes to meaningful use requirements following the publishing of modifications to Stage 2 Meaningful Use and requirements for upcoming Stage 3 in October by the Centers for Medicare & Medicaid Services (CMS).

As a result, it's worthwhile in light of the AHA's most recent comments to recap the similar recommendations made by these industry groups representing large constituents of healthcare organizations and professionals.

"Experience to date indicates that the transition to new editions of certified EHRs is challenging due to lack of vendor readiness, the necessity to update other systems to support the new data requirements, the mandate to use immature standards, an insufficient information exchange infrastructure and a timeline that is too compressed to support successful change management," AHA Executive Vice President Thomas P. Nickels states.

Postponing the start of Stage 3

Neither AHA nor CHIME wants the next stage of the EHR Incentive Programs to begin prior to 2019. For its part, the former is seeking alignment between meaningful use requirements and those likely to come out of the Medicare Access and CHIP Reauthorization Act (MACRA).

Both organizations have pointed to provider struggles with previous stages of meaningful use as proof that the program's timeframe does not reflect experience-to-date of eligible hospitals and professionals whose success in Stage 1 did not carry over into Stage 2.

"All providers require sufficient time to implement and upgrade technology and optimize performance before moving to more complex requirements for use," adds Nickels.

Eliminating all-or-nothing approach

The American Medical Association (AMA) was likely the first industry group to advance this notion, but it now has company.

AHA, CHIME, and the aforementioned organization all seek the removal of the all-or-nothing thresholds required by the EHR Incentive Programs. AHA goes so far as to set the bar at 70 percent for EPs and EHs in successfully demonstrating meaningful use.

Reducing reporting burden on providers

Here AMA and CHIME are in agreement. The former was much more explicit in calling on CMS to allow providers to get the most out of the data they already have that can be used for the EHR Incentive Programs, Alternative Payment Models (APMs), and the Merit-based Incentive Payment System (MIPS).

Advancing interoperability

AHA, CHIME, and AMA all agree that Stage 3 needs to play a significant role in advancing interoperability and therefore must change significantly in order to do so.

For AHA, it's about use cases. "Prioritization of use cases that accelerate the exchange of the current meaningful use data set that is being captured to support care will build confidence and support for tackling the capture and exchange of additional data elements," writes Nickels.

Echoing AMA, the organization emphasized the need for more time for the healthcare and health IT community to address the issue. "The AHA urges CMS to allow the current market pressures for information exchange from consumers and from new care delivery models to accelerate demand for information exchange," added Nickels.

Many more recommendations comprise the letters from these industry groups to CMS, but a consensus is growing more steadily for some changes.

Four general policies and developments could help speed up the interoperability initiative.

As a part of a federal mandate to improve EHR use, interoperability, and connected care, the Health IT Policy Committee (HITPC) has submitted its December report to Congress explaining barriers and policy suggestions with regard to interoperability.

Develop Health Information Exchange (HIE) Measures

The first policy suggestion the HITPC explained to Congress was the establishment of HIE-sensitive measures which would not only measure the amount of information providers were exchanging amongst one another, but the meaningfulness and impactfulness of that information. In order for providers to receive high scores on these measures, the information exchanged would need to be used meaningfully, as to reflect an important use of the information.

“In order to enhance the strength of incentives that drive interoperability, a set of specific measures should be developed that focus on the delivery of coordinated care, facilitated by shared information across the entire health team (including the individuals and families) and throughout the continuum of care settings,” the HITPC explained. “An example of an HIE-sensitive measure would look at medically unnecessary duplicate testing.”

This new policy could be effective in strengthening incentives by first allowing payers to incorporate these measures into their payment methods, and second by integrating these measures into public reporting that would in turn reveal which providers give the highest level of coordinated care.

Develop Vendor HIE Measures for Certification

Just as providers should be tested against certain HIE-sensitive measures, as should vendors. Such measures could potentially serve as a direct catalyst to improve vendor developments and performances.

Specifically, HITPC is looking for these measures to occur in practical use -- not in a lab -- and to take into account needs that go beyond certification measures for the EHR Incentive Programs.

“Today, purchasers of EHR systems lack such measures to inform purchasing decisions or to use as a lever to put pressure on vendors to improve,” HITPC confirmed. “Although vendors have strong incentives to pass the interoperability requirements for EHR certification, this process is “one-time” and occurs in a lab. It has not been shown to translate into interoperability that is affordable or easy to implement in the field.”

HITPC also listed a few specific measures that could record vendor HIE performance:

Number of data exchanges from external sources, which could include other providers, community social-service organizations, consumers, payers, etc. (denominator that measures ability to exchange data with another electronic system such as an EHR, HIE or consumer application (app));

Percentage of time viewing of external data changed current activity (e.g., appeared in clinical decision support, led to change in order being written), which demonstrates impact of external data.

Accelerate Incentive Payments for Interoperability

HITPC maintained that in order for providers and vendors to make interoperability progress, they must have adequate incentive payments. Not providing incentive payments encourages providers to deal with internal needs rather than prioritize interoperability.

Today, the lack of palpable financial incentives for interoperability favors the status quo. Pressing internal priorities compete for attention and resources are needed to achieve interoperability, especially when specific actions to enact interoperability are complex and time-consuming. This results in slow progress. Moving interoperability up the priority list will likely take financial incentives that are more targeted than a broad shift from fee-for-service to pay-for- 17 value. To have the desired effect, the incentives must be strong and specific, with clearly defined measures and a deliberate implementation timeline and effective dates.

Initiate Sustained Multi-Stakeholder Action

In order for the above-mentioned goals to be met, HITPC explained that multiple stakeholder groups will need to take action in the overall interoperability efforts. Several of the policy suggestions, such as creating HIE-sensitive provider measures, require multiple voices for development, and multiple interpretations of the ONC Interoperability Roadmap.

Thus, HITPC suggested creating an interoperability Summit of various industry stakeholders in order to collaborate on interoperability efforts.

The output of the Summit would be an action plan with milestones and assigned accountabilities for achieving the milestones in the context of this larger interoperability initiative. We expect the compelling call-to-action would engage the stakeholders to continue their activities after the Summit as a way of meeting the payer-driven incentives that reward HIE-sensitive measures of coordinated care.

Earlier this year, Congress requested a report from the Office of the National Coordinator for Health IT (ONC) which detailed the issues surrounding information blocking. In the report, the ONC both defined information blocking as a practice, and provided examples.

Specifically, ONC defined information blocking as using criteria of interference, knowledge, and lack of justification for refusing to share information.

The information provided in this most recent report from HITPC could potentially put an end to those negative information blocking practices by providing incentives for fostering HIE and interoperability. Between monetary incentives and a clear prescription of HIE measures, both providers and vendors could ideally implement more effective interoperability strategies.

Different EHR vendors perform better in various different countries, according to a new KLAS Global Performance Report.

Despite having distinct popularity and success throughout the United States, Epic Systems is not necessarily the top-performing EHR product throughout the globe, according to a recent KLAS report.

The KLAS Global Performance report breaks down user-perceptions of various different EHR systems by region, such as Asia/Oceania, Europe, Latin America, the Middle East, and North America. Results show that although Epic Systems receives high praise throughout the US, and also performs well in Europe, the vendor does not have a stronghold in other regions.

The the best vendor performances in multiple regions, in fact, belonged to Cerner and Intersystems with high performances in Europe, Asia, and the Middle East.

One of the significant barriers vendors face in implementing their systems abroad are state contracts which limit certain functionality. Several companies, such as Cerner and Intersystems, have trouble implementing in Australia due to contractual issues.

Cerner’s implementation in the UK serves as an example of EHR systems that can be successfully implemented provided full adoption and fewer contractual limitations.

Although Epic is not seeing solid performances or high adoption rates in all regions, it is seeing success at larger health systems in other countries. Of the seven international Epic users interviewed, all of them reported full adoption of the systems, and strong functionality and support.

Vendors that do not see success at larger health systems include Allscripts and Phillips. Allscripts users report complications with implementation and support, while Phillips states that it faces difficulty garnering larger users to adopt their systems.

Cerner has garnered the most success throughout Europe, with the most ubiquitous successful adoption throughout the entire continent. That said, Epic has nearly 100 percent approval ratings from European users, though they are almost entirely located in one nation (the Netherlands).

As previously stated, Cerner’s clients in Australia are having difficulty with implementation. This is because of the way in which user contracts are established. Reported issues include a need for increased functionality, more system training, and increased systems optimization.

Despite Epic’s inconsistent international ratings, the EHR vendor continues to prove successful in the US. Between Epic’s many users’ awards, as well as Epic’s own honors, the vendor maintains its foothold as a health IT giant.

Additionally, Epic won out in a recent Peer60 study of the physician-ranked most innovative EHR systems. Among the C-suite executives surveyed in the study, Epic won out as the overall best EHR system in operation. The vendor was also selected as one of the most intuitive and easy-to-use models on the market, and the top choice for CIOs.

Cerner and its users were also successful in the US this year, receiving KLAS’s best small ambulatory EHR award for 2014. Cerner also received two other KLAS awards in 2014.

In the aforementioned Peer60 study, Cerner was ranked as one of the most intuitive models on the market, as well as a top choice for COOs.

Perhaps most notably, Cerner was recently selected as the choice EHR for the Department of Defense EHR modernization project in partnership with Leidos Partnership for Defense Health. The partnership, which is currently valued at approximately $9 billion, was a significant feat for the EHR vendor.

“The Leidos Partnership for Defense Health is honored to have partnered with the Military Health System for nearly three decades, and we are committed to continuing our work in support of its mission to improve the health and medical readiness of our military,” Leidos representatives said in a public statement. “Our team stands ready to lean forward with the DoD to implement a world class electronic health records system.”

I love traveling for a variety of reasons. One of the biggest is the ability to meet a diverse group of people who start as strangers and become friends. On a recent trip to San Francisco, I had breakfast with an IT professional working in the banking industry. Our conversation turned to the proliferation of data in both of our worlds, and how it can complicate the analysis and productive use of that data.

I have worked as a PA for more than 34 years, and have witnessed a dramatic transition of how we collect and view patient health records, from paper records and manual charting to the modern EHR and computerized physician order entry (CPOE) systems.

In my travel buddy’s banking world, similar to the medical world, data management is an expensive proposition. The size and complexity of the data expands exponentially every year. Software is the interface between professionals in our fields, allowing us to interpret and record information into this burgeoning database.

It has dawned on me on more than one occasion that the weak link in this whole system is the end user, and this is true for every industry. I have observed over the years the age diversity of physicians, PAs and others providers directing patient care within the healthcare system in the U.S. Prior to computers and digital data, we all charted the same way. The only tool that we all had was pen and paper. This has changed dramatically over the past ten years.

A number of policy changes on the federal level, as well as the Affordable Care Act, have driven a rapid transition to the EHR at every level of the healthcare system. A combined carrot and stick economic stimulus has been the force behind this transition. It has, at times, been challenging from a provider standpoint. I imagine that it has been the same from the corporate level.

I can only address the view from the trenches. What used to be a uniform documentation system has moved into one in transition. We don't allow anything but CPOE in our hospital. However, we still allow handwritten progress notes. Administration has moved gently in this area in order to cater to some providers’ lack of computer skills. While everyone is different, having practiced healthcare for many years, technology adoption can fall into several transitive groups.

Today’s recent medical professionals are highly computer literate, and have never touched a paper record, and never will. They can research a patient problem, FaceTime with their friends, text, and handle e-mail all at the same time, from a variety of devices.

Then, there is a middle group who have grown up in the computer era and have decent computer skills. They remember the paper era, but see the promise of the digital age and are able to keep their heads above water in the burgeoning digital age.

The last cohort is my age group, those nearing retirement who have spent the majority of their careers in medicine in the paper age. Many in this age group find managing technology to be a frustrating endeavor. However, with challenges and transitions come opportunities and I have seen many baby boomers and hospitals adapt to leverage more holistic systems. It simply takes patience and a little bit of flexibility.

That said, we have to be gentle in our expectations of the transition towards a digital world. Big organizations, like the one running the hospital in which I work, have deployed many resources towards easing the transition towards the EHR that are available 24/7.

Unfortunately, some providers in private practice might not be so lucky, and find themselves having to go it alone. Assisting all those at every level of EHR skill and ability is imperative toward full implementation of the EHR.

Patience is an important virtue in this transition. Nothing this difficult and complex can be done easily or quickly. However, by being reasonable and rational about the problem that we are trying to solve — being flexible and ensuring we are building tools that will ultimately allow us to better serve our patients — will help with the solutions towards dealing with the mountain of data that is burying every industry in the nation, service or otherwise.

Adhering to patient safety standards is of vital importance when using an EHR, which is why proper review and research among different systems are critical for innovation. However, are supposed gag clauses in EHR vendor contracts inhibiting this kind of review and research?

A recent Politico article written by Darius Tahir presents considerable research into the matter. According to Tahir, EHR users are being completely prohibited from sharing adverse events and negative feedback regarding their EHRs. This stems from different gag clauses included in EHR vendor contracts, and seriously affects innovation that can help improve patient safety.

But HealthAffairsarticle by Kathy Kenyon, JD, MA, tries to clarify many of the legal implications of EHR vendor contracts, and discusses the realities of the “gag clauses.”

According to Kenyon, gag clauses in EHR vendor contracts do not necessarily prohibit users and researchers from offering negative feedback regarding their EHR systems. However, as soon as users or researchers include a screenshot of an EHR screen in their critique, they are breaching the “gag clauses” that actually deal with protecting intellectual property.

Kenyon states that many EHR vendor contracts include clauses that prohibit users from publically sharing screenshots of the EHR while reviewing the product without vendor permission. These clauses exist to protect the intellectual property of EHR vendors. However, they are actually quite vague and unclear, giving vendors the power to prohibit potentially vital research that could improve the EHR for patient safety.

“The true ‘gag clause’ problems with EHR vendor contracts appear to be related to the confidentiality and intellectual property terms, which are overbroad and unclear, and limits on ‘authorized uses’ of the EHR, as those terms apply to research and reporting that requires access to the EHR and use of screenshots,” she writes.

Furthermore, when researchers are able to access screenshots to share information for system improvement, vendors are given a high level of control regarding what system information is released. This potentially prevents unbiased information from being published, hindering the improvement process.

“As long as researchers must ask vendors for permission to do research or to publish screenshots, and as long as vendors can deny permission for any reason, including not liking the results, there is a serious danger that research will be designed and findings presented in ways that garner vendor permission,” she writes.

Kenyon points out that these clauses exist to protect the intellectual property of EHR vendors. The vendors are concerned that should information regarding the look and functionality of their software be released to the public, other vendors may steal these features. This would cause vendors to lose “competitive advantage,” Kenyon says, and would hurt the business of the EHR industry.

Kenyon says that many EHR users state that this fear of vendors is not entirely well-founded considering the ease with which competitors are able to gather information regarding a certain EHR.

“...it is not that hard to discover what different EHRs look like. For vendors hoping to improve their EHRs by ‘stealing’ from others, waiting for research with screenshots to be published would be an exceptionally inefficient way to do so,” she writes.

Furthermore, many physicians maintain that no price can be put on the safety of patients, Kenyon reports.

Kenyon maintains that under existing contracts, the provisions made to protect intellectual property are not functional for researchers. To increase patient safety while using EHRs, different standards are going to have to be implemented, Kenyon suggests.

“Stakeholder groups for patient and EHR safety, including parties to EHR contracts, should share interests in making health IT safety-related research and reporting as easy as possible,” Kenyon explains. “EHR vendor contracts should reflect as much consensus on these issues as is possible.”

She continues to provide suggestions for the construction of future EHR vendor contracts, stating that there should be no gag clauses, but rather clauses that encourage research and encourage reporting of adverse outcomes. By identifying these areas for improvement in EHR vendor contracts, research and adverse event reporting may potentially help increase patient safety.

October 1 has come and gone, and nearly two weeks in to ICD-10 compliance most of the healthcare industry is relatively mum on the transition to the newer clinical diagnostic and procedural code set. More than likely, healthcare organizations and professionals are busy enough adapting to ICD-10 and its more specific set of codes.

That’s not to say some are not speaking out or in support of ICD-10 compliance.

Two recent weekend reports in the Florida’s Crestview News Bulletin and Maine’s Bangor Daily News paint two very different pictures of ICD-10 compliance at the two-week mark.

Apparently, some physician practices in the Florida panhandle are going through the motions in adapting to the federal mandate for ICD-10 compliance which began back on October 1. Brian Hughes reports that medical offices are encountering difficulties with the code set.

“Large practices and medical companies, such as Peoples’ Home Health, usually have coders on staff. Their only job is to enter the numbers into billing records and insurance reimbursement forms,” he writes. “For smaller offices like Dr. Herf’s and Mir’s, the increased coding tasks take away staffers’ time with patients.”

Betty Jordan, the manager of physician practice of Abdul Mir, MD, views ICD-10 as more of a hindrance than a help.

“It requires so much extra work. If my doctor treated someone for rheumatoid arthritis, there’s hundreds of codes. It’s got to be specific,” she told the Crestview News Bulletin.

“It is horrible for a primary care doctor,” she further revealed. “For a specialist, they deal with the same things over and over. For us in family practice, we see all kinds of things. It’s overwhelming.”

For an administrator at the practice of David Herf, MD, the challenge of ICD-10 compliance is the result of increased specificity being married to an increase amount detail.

“It’s really, really detailed,” Andrew Linares told the news outlet. “Instead of just saying, ‘cyst of the arm or trunk,’ you have to get really specific.”

For one of the physician practices, adapting to ICD-10 is akin to learning a whole new language.

The climate in Maine appears much sunnier regarding ICD-10 compliance. Jen Lynds reports high levels of preparation among Maine healthcare organizations and professionals leading to a smooth transition.

“Health care providers across the state began working Oct. 1 with a new system of medical codes that has them describing illnesses and injuries in more detail than ever before, and officials from hospitals and medical associations said earlier this week that they are prepared for the challenge,” she writes.

According to Gordon H. Smith, the Executive Vice President of the Maine Medical Association, complaints are scarce as are ICD-10 implementation delays. Director of Communications for the Maine Hospital Association reports the same situation.

That being said, leadership at Eastern Maine Medical Center are preparing for transition-related productivity decreases for coders and billers used to the previous code set. However, things are still proceeding as planned.

“Our transition to ICD-10 has gone very smoothly here at Eastern Maine Medical Center,” Director of Coding and Clinical Documentation Improvement Mandy Reid told the Bangor Daily News. “We are using nine contract coders through outside vendors to support the ICD-10 go-live, and we secured them several months ago to be prepared. We also have added three positions in the outpatient area to help support growing volume, as well as ICD-10 coding.”

The lesson learned so far is that a clinical practice’s ability to invest in ICD-10 preparation (e.g., training) correlates to its present-day confidence in ICD-10 compliance.

"Ultimately, the data from this study demonstrate that during safety-critical tasks and times, patient safety is negatively affected, in part because mistakes and critical use errors occur more frequently and because users are highly frustrated, and thus more likely to employ workarounds, such as relying upon supplemental artifacts, e.g., paper ‘shadow charts’ or whiteboards," the authors conclude.

clinically relevant information being unavailable at the point of care

lack of adequate EHR clinical documentation

inaccurate information present in the clinical record

inability to retrieve clinical data

Based on empirical analysis of inpatient and ambulatory EHR use, the NIST document proposes three EHR usability enhancements that EHR technology incorporate to eliminate or reduce risks to patient safety.

The first centers of how critical patient identification data is presented. According to NIST, this information should be presented in a reserved area. The authors of the report recommended reserving the upper left-hand corner of all screens or windows and remain persistent regardless of scrolling or navigation throughout the EHR. Additionally, they hold that a patient's name appear with last name first, followed by first and middle names, modifiers, data of birth, age, gender, and medical record number (MRN) number. For EHR mobile technology, the NIST guidance allows for the presentation of this information horizontally to maximize screen space.

The second enhancement calls for the use of visual cues to "reduce risks of entering information and writing orders in the wrong patient's chart." The enhancement would prevent EHR users from entering information into multiple charts simultaneously as well as visually different between read-only and editable charts. Under this guidance, EHR users would have to deliberately enable the software to move between charts and maintain unrestricted access and provide clear cues when an EHR user moves between charts.

The third and final enhance places an emphasis on supporting the effective identification of "inaccurate, outdate, or inappropriate items in lists of group information by having information presented simply in a well-organized manner." The NIST document contains several examples:

3.1 Lists of patients assigned to a particular clinician user should be presented in consistent, predictable locations within and across displays and print-outs and the content should not vary based on display location.

3.2 The status of a note and order as draft as compared to final shall be clearly indicated on appropriate displays.

3.3 Clearly indicate the method by which the system saves information, whether auto-save or requiring deliberate action to save, or combinations thereof.

3.4 Inputted information should be automatically saved when a user transitions from one chart to another.

3.5 The language used should be task-oriented and familiar to users, including being consistent with expectations based upon clinical training.

3.6 Enable a user to easily order medications that have a high likelihood of being the appropriate medication, dose, and route. The likelihood is increased when displays are tailored to specialty-specific user requirements, comply with national evidence-based recommendations, are in accordance with system, organizational, unit, or individual provider preferences specified in advance, or are similar to orders made by the same physician on similar patients, on the same patient in the past, or providers with similar characteristics.

3.7 Support assessing relationships of displayed information and allowing users with appropriate permissions to modify locations and relationships for inaccurately placed information, including laboratory results, imaging results, pathology results, consult notes, and progress notes. This includes information within a single patient’s chart as well as information placed in the wrong patient’s chart. The information about the time and person that made the change should be viewable on demand.

On top of these recommendations, the guidance provides two use cases to illustrate the components of EHR usability testing in identifying and mitigating potential patient safety risks in both inpatient and outpatient settings.

Throughout my HIM career, I have seen many different methods of capturing clinical documentation. We are always looking for solutions to get accurate and complete clinical documentation into the medical record in a timely manner with minimal disruption to the provision of care. The processes for gathering documentation have evolved with advances in technology and HIM professionals have been very involved in ensuring the quality of the documentation.

When I first began working in an HIM department, we had a Transcription department with hospital-employed transcriptionists and a management team devoted to medical transcription. Quality reviews were performed regularly and the transcriptionists had an ongoing relationship with the physicians to provide feedback and get clarifications. As part of this department, there were file clerks in charge of filing the transcribed documents onto the paper medical records throughout the day and into the night. When I think back on these practices, it seems like an entirely different lifetime from today’s practices yet it really wasn’t that long ago.

Over time, transcriptionists began to disappear from hospitals as the task became outsourced. Vendors have offered to do the job for less cost and they guaranteed a high quality rating of the transcribed reports. However, transcribed reports often still come back to the medical record with blanks and anomalies that must be corrected by the dictating clinician which can delay the documentation reaching the chart. It’s important to review documents to make sure there are no obvious errors that may have been misinterpreted by the transcriptionist or the back-end speech recognition system.

Many are still relying on outsourced transcription as a major source of capturing documentation but this is evolving as EHRs have created new opportunities for documentation. EHRs provide documentation tools such as templates to import data into the notes and allow for partial dictation for the narrative description. The negative side of this is that copy and paste is used frequently due to the ease of grabbing documentation from the rest of the EHR and pasting it into the note to save time. Clinicians using copy and paste may not realize that the information could be outdated or it could be against company policies. This now requires quality reviews to monitor the use of copy and paste and the relevance of the documentation to maintain the integrity of the medical record. This should be incorporated into chart audits or other quality review processes.

Front-end speech recognition tools are popping up frequently as an additional tool to capture documentation. A concern with this is the shift from having quality reviews performed by the transcriptionist to now relying on the clinicians to edit their documentation as they dictate. Many are creating positions in HIM departments to perform quality reviews on the documentation to not only ensure the documentation is in the record in the adequate timeframe but making sure the documentation is accurate for each patient. It will be interesting to see how clinical documentation continues to evolve as new methods of capturing documentation are developed and deployed. No matter how the information gets into the medical record, HIM professionals still have the ultimate responsibility to ensure the quality of the documentation for patient care and appropriate reimbursement.

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